More than thirty years have passed since the first “revolution in mental health”—the deinstitutionalization movement that moved patients out of segregated mental health hospitals and, in theory, back into their neighborhoods to be with their families. But a generation later, many are still waiting to receive basic care in their communities—the therapy they require to live with the dignity and freedom the movement fought for.
Earlier this month, mental healthcare workers across California went on strike to show that everyone’s tired of waiting—patients are tired of delayed appointments, workers are exhausted by understaffing and stalled contract talks, and the system suffers from an outmoded infrastructure that fails to meet growing community needs.
Clinicians at the healthcare and insurance giant Kaiser Permanente simply want the company to follow the law: California’s relatively progressive mental health parity regulations mandate that providers offer mental health services “under the same terms and conditions applied to other medical conditions.” Meanwhile, the added insurance resources of the Affordable Care Act have raised hopes for reform.
But Jim Clifford, a psychiatric social worker at a Kaiser center in San Diego, one of thirty-five locations that went on strike statewide says that due in part to the “stigma associated with mental health,” the field has been marginalized, leading to a “relegation at Kaiser of psychiatric services to this second-class level.”
At his clinic, serving a diverse urban population, the staff must stretch to make ethically impossible choices: “We are staying late making phone calls back to patients that we weren’t able to get appointments for, to check in and see how they’re doing. The doctors have to double and triple book their schedules. The nurses usually are here before they’re on the clock and typically stay well past their paid time to try to catch up to all the extra contact that’s made necessary by the fact that we don’t have enough staffing.”
Elizabeth White, a psychiatric social worker at Kaiser West Los Angeles, tells The Nation that facing a staffing and space shortage at her facility, “the manager’s been really creative at turning closets into offices, and partitioning group rooms. But the main piece is [Kaiser regional management] really haven’t thought through their demand, to create an environment that is healing…. At five o’clock we have three different [therapy] groups starting, and the line’s out the door.”
And some patients may be simply walking out the door. Chelsie Martinez of Sonoma County recalls that Kaiser typically made her wait about six to eight weeks for one-on-one therapy appointments for post-traumatic stress and other emotional problems, which previously drove her to attempt suicide. She says that though she preferred individualized care, Kaiser pressured her to engage in group sessions. She was told, “I wasn’t participating as they thought I should be, and that I needed to be more involved.” But she protested, “I just couldn’t do groups as they were really not helping.” She eventually left Kaiser’s services to pay for private individual therapy, and says now, “although the expenses are a bit more, my mental health has never been better and I’m not willing to give that up.”
But many others may be unable to afford services outside of Kaiser’s insurance system. They’re stuck with a service infrastructure that has, despite billions in annual profits, been criticized for years for poor services and inadequate performance monitoring. A 2013 state audit found that despite a standard two-week wait time for non-urgent appointments, at one facility, “between 18 percent and 32 percent of the wait times exceeded 14 days.” Kaiser got fined $4 million for various service deficiencies, and has faced various patient lawsuits.
The union, National Union of Healthcare Workers (NUHW), complained last June of systematic violations of standards of care in a letter to Attorney General Eric Holder, citing a facility in Redwood City that reportedly “experienced an unprecedented spate of seven suicides in a matter of months, which clinicians believe is directly connected to the serious understaffing of Kaiser’s mental health clinics.”
While many converging problems have created the crunch, including rising enrollment as well as chronic understaffing and inadequate recruitment efforts, the bottom line is that these patients are insured, yet their needs have been neglected on an epidemic scale.
The crisis at Kaiser may intensify as the Affordable Care Act enrolls more people in new insurance plans. Moreover, these service gaps at private insurers come in a context of a nationwide mental health crisis, with massive unmet needs among highly vulnerable populations, like the uninsured, children, and the incarcerated.The union’s seven-day strike was their most dramatic call yet to resolve the staffing shortages not just with acute care—recruiting and hiring more staff for facilities with service gaps—but also preventive measures: a new system to incorporate clinicians themselves into key personnel decisions.
NUHW President Sal Rosselli says that empowering staff themselves to participate in decisions on personnel needs is the most ethical and efficient way to manage growing care needs: “Our simple proposal was that we establish a committee of psychologists and managers at each clinic that work on the staffing situation for that hospital or clinic, and come up with a resolution.” A third-party mediator could be called upon to resolve disputes.
For now, NUHW’s negotiations are set to resume with Kaiser, and their agreement could set a nationwide template for mental health parity.
Kaiser, which recently negotiated another hard-fought contract with the California Nurses Association, said in a statement to The Nation, “We remain ready to return to the table,” but “this agreement must be one that best serves our employees, members and patients.” It called the strike “entirely unnecessary and counterproductive.”
But the workers know what “unnecessary” looks like. Despite the corporation’s repeated vows to strengthen services, Clifford says it should start with a basic ounce of prevention: timely initial appointments and responsive staff. That way, “Not only can we avoid some of the more expensive outcomes”—including costly hospitalizations—“but also we can provide a more ethical treatment, and avoid and decrease a lot of the…needless suffering that’s going on.”
Paradoxically, striking was a demonstration of care amid crisis: workers felt the least “counterproductive” way to use their labor was to withhold it to send Kaiser a message: waiting a week for services was still a much shorter delay than what they and their patients deal with every day.